Predictors of Disengagement in Care for Individuals Receiving Pre-exposure Prophylaxis (PrEP)

Abstract

Background: HIV pre-exposure prophylaxis (PrEP) reduces incident HIV infections, but efficacy depends on adherence and retention, among other factors. Substance use disorders, unmet mental health needs, and demographic factors are associated with nonadherence in HIV-infected patients; we studied whether these affect PrEP retention in care.

Methods: To investigate potential risk factors disengagement in a comprehensive HIV prevention program, we conducted a retrospective cohort analysis of individuals starting tenofovir-emtricitabine between January 1, 2015, and November 30, 2017. The primary outcome was adherence to the initial 3-visit schedule after PrEP initiation.

Results: The cohort was predominantly African American (23%) and Hispanic (46%). Race, ethnicity, substance use, patient health questionnaire 9 score, insurance, and housing status were not associated with retention at the third follow-up visit. Age <30, PrEP initiation in 2017, PrEP initiation in the sexual health clinic, and PrEP same-day start were associated with lower retention; male gender at birth, transition from post-exposure prophylaxis (PEP) to PrEP, feeling that they could benefit from, or participating in mental health services were associated with increased retention. Overall, retention in HIV preventative care at the first follow-up visit (68%) and third follow-up visit (35%) after PrEP initiation was low.

Conclusion: Clinic services and ancillary services (such as mental health) may facilitate retention in care. In this study, select social and behavioral determinants of health were not found to be linked to retention. Focused investigation of reasons for dropout may elucidate the challenges to maintaining individuals in PrEP care and direct resource allocation to those in greatest need.

Figure 1:

Pre-Exposure Care Cascade for Individuals Starting PrEP from 1/1/2015 through 11/30/2017 and followed through 9/30/2017 for Retention in Care Through the First Three Visits and Re-Engagement at Any Time. *”First follow-up visit” was defined as having a visit between day 14 and day 60 or documentation of enough prescription refills to last within one week of the second follow-up visit. **”Second follow-up visit,” was defined as having a visit between day 60 and day 165, and no more than 120 days from prior visit, or documentation of having prescription refills to last within one week of the visit. ***”Third follow-up visit,” was defined as completing second follow-up visit and having a visit between day 135 and day 285, no more than 120 days from prior visit, or documentation of having prescription refills to last within one week of the visit.